Benign Diseases of The Vulvavagina and

Benign diseases of the
vulva, vagina and cervix

The vulva
Is the part of the female genital tract located between the
genitocrural folds laterally, the mons pubis anteriorly, and the anus
posteriorly.
Embryologically, it is the result of the junction of the cloacal
endoderm, urogenital ectoderm, and paramesonephric mesodermal
layers.
This hollow structure contains
LABIA MAJORA
LABIA MINORA
CLITORIS
VESTIBULE
URINARY MEATUS
VAGINAL ORIFICE
HYMEN
BARTHOLIN GLANDS
SKENE DUCTS.
The vulva
Different epithelia, from keratinized squamous epithelium
to squamous mucosa, cover the vulva.
The labia minora are rich with sebaceous glands but
have few sweat glands and no hair follicles.
The epithelium of the vestibule is neither pigmented nor
keratinized and contains eccrine glands.
BENIGN LESIONS OF THE VULVA
According to the International Society for the Study of

Vulvar Disease (ISSVD) in 1989:
Inflammatory diseases.
Blistering diseases.
Pigmentary changes.
Benign tumors, hamartomas and cysts
Congenital malformations.
Inflammatory diseases
1. Lichen sclerosus 12.Psoriasis

2. Squamous cell hyperplasia (+/- atypia) 13.Reiter disease
3. Lichen simplex chronicus (localized 14.Lichen planus
neurodermatitis) 15.Lupus erythematosus
4. Primary irritant dermatitis 16.Darier disease
5. Intertrigo 17.Aphthosis and Behet disease
6. Allergic contact dermatitis 18.Pyoderma gangrenosum
7. Fixed drug eruption 19.Crohn disease
8. Erythema multiforme 20.Hidradenitis suppurativa
9. Toxic epidermal necrolysis 21.Fox-Fordyce disease
10.Atopic dermatitis 22.Plasma cell vulvitis
11.Seborrheic dermatitis 23.Vulvar vestibulitis syndrome
Blistering diseases
1. Familial benign chronic
pemphigus (Hailey-Hailey
disease)
2. Bullous pemphigoid
3. Cicatricial pemphigoid
4. Pemphigus vulgaris
5. Erythema multiforme
6. Epidermolysis bullosa
Pigmentary changes
1. Acanthosis nigricans
2. Lentigo
3. Melanocytic nevus
4. Postinflammatory hyperpigmentation
5. Postinflammatory hypopigmentation
6. Vitiligo
Benign tumors, hamartomas, and
cysts
1. Bartholin cysts 8. Hidradenoma
2. Epidermal inclusion cyst (Dermoid cyst) 9. Lipoma
3. Endometriosis 10. Chronic Inflammatory swellings
4. Hydrocele of the canal of Nuck 11. Hemangioma
5. Skene duct cyst 12. Lymphangioma
6. Seborrheic keratosis 13. Angiokeratoma
7. Acrochordon (fibroepithelial polyp) 14. Pyogenic granuloma
8. Fibroma, fibromyoma, and dermatofibroma 15. Sebaceous gland hyperplasia

16. Papillomatosis
BENIGN LESIONS OF THE VULVA
BARTHOLINs CYST
ATROPHIC LICHEN (LICHEN SCLEROSUS ET ATROPHICUS)
SQUAMOUS HYPERPLASIA
LICHEN SIMPLEX CHRONICUS
HIDRADENOMA PAPILLIFERUM
Bartholins Cyst/Abscess
Medial to labia minor
Blockage of duct following infection

N. gonorrhea
Staphylococci
Anaerobes
Thomas Bartholin
Danish professor
In 1652 he gave the first full
description of the human
lymphatic system.
Marsupalization
lichen
What is lichen?
A fungus, usually of the class Ascomycetes,

that grows symbiotically with algae, resulting
in a composite organism that
characteristically forms a crustlike or
branching growth on rocks or tree trunks.
In pathology.
Any of various skin diseases characterized by

patchy eruptions of small, firm papules.
Lichen Sclerosus et Atrophicus
Most patients are post-menopausal women
Stenosis of the introitus develops

Note the white, parchment-like or plaque-like lesion

During early stages the patient may not have symptoms.
Some patients develop intractable pruritus
Burning and pain are less likely manifestations.
Figure-of-8 or keyhole configuration.
In late stages normal architecture may be lost

atrophy of the labia minora, constriction of the vaginal orifice
(kraurosis), synechiae, ecchymoses, fissures.
Squamous cell carcinoma develops in 3-6% cases

Thinning of the surface epithelium with some

hyperkeratosis.
Etiology
Unknown. A higher prevalence of the disease in
postmenopausal women suggests hormonal factors,
but this has not been confirmed.
Studies identifying an infection are inconclusive
Weakly linked to autoimmune diseases and genetic
factors
Local factors (eg, trauma, friction, chronic infection
and irritation)
Recurrence near vulvectomy scars has been
observed.
Treatment
Potent topical corticosteroids
Testosterone propionate is ineffective and has

many adverse effects
Close follow-up -----epithelial cancer.

Squamous Hyperplasia
Associated with a response to hormonal
influences or exposure to exogenous irritants
Precursor of squamous cell CA if cells are
atypical
This lesion produces hyperplastic thickening of the

superficial squamous epithelium.
This lesion is a precursor of squamous cell carcinoma
of the vulva
Note the keratin horn cysts and the infiltrate of

inflammatory cells at the base of the lesion.
ITCHING is a common symptom.
If hyperkeratosis is not prominent, lesions may appear

as reddish plaques.
The clitoris, labia minora, and inner aspects of the labia

majora are more commonly affected.
Extensive lesions may result in stenosis of the vaginal

introitus.
Etiology
Repetitive scratching or rubbing from irritants
Treatment is aimed at halting the
itch-scratch-itch cycle.
Treatment
The same as lichen sclerosus
General attention to proper hygiene.
If the skin is moist or macerated, aluminum acetate
5% solution applied 3-4 times daily for 30-60 minutes
is beneficial.
Systemic antihistamines or tricyclic antidepressants
Refractory lesions, intralesional injections of
triamcinolone acetonide may be an alternative.
lichen simplex chronicus
Hyperkeratotic, usually ill-defined,

grayish, thickened, and sometimes
excoriated lesion.
Usually located over the labia

majora.
Hyperpigmentation.
Itching is always present and may

be intense.
Lichen simplex chronicus of the vulva is the end stage of
the itch-scratch-itch cycle.
The initial stimulus to itch may be:
Underlying seborrheic dermatitis.
Intertrigo
Tinea.
Psoriasis.
In most cases, the underlying cause is not evident and may have
been transient vulvitis or vaginal discharge.
Any itching disease of the vulva may become secondarily
lichenified.
Epidermal and epithelial hyperplasia,
Hyperkeratosis.
Fibrotic vertical streaks of collagen between the
hyperplastic rete are present.
Treatment
Includes removal of irritants and/or allergens
Topical application of mild-to-highpotency corticosteroids.
Avoid soaps and cleansing agents other than aqueous cream.
Discourage excessive cleaning of the genital area; use of hot
water; overheating; and wearing of synthetic, rough, and/or
tight clothing.
Lichen simplex chronicus may be associated with

underlying diseases (eg, Paget disease, Bowen disease)
Lichen planus
Three types:
Papulosquamous
Erosive
Hypertrophic
Malignancy is possible in long-standing and ulcerative

lichen planus.
Lichen planus
The papulosquamous form:
Occurring as part of a generalized
disease
Is the most common and is
characterized by:
Flat-topped
Polyhedral,
Violaceous, shiny, and itchy papules
located on keratinized skin of the
labia and mons pubis. Delicate and
whitish reticulated papules may be
present on the mucosa, but no
atrophy or scarring is observed.
Lichen planus
The erosive form:
Involves the mucous membranes of the mouth and vulvovaginal
area and may be locally destructive, leading to atrophy and
scarring.
Synonyms include erosive vaginal lichen planus, desquamative
inflammatory vaginitis, vulvovaginal-gingival syndrome, and
ulcerative lichen planus.
Itching is rare, but pain, burning,

and irritation occur and may be
responsible for dyspareunia and
dysuria.
Lichen planus
The rare hypertrophic form:
Resembling lichen sclerosus, manifests
with extensive white scarring of the
periclitoral area with variable degrees of
hyperkeratosis.
It may be very itchy.
Extensive vaginal involvement may result
in a malodorous discharge.
Large denuded areas may become
adherent, causing stenosis of the vaginal
introitus and dyspareunia.
Marked atrophy may develop with time.
ID/CC A 75 year old woman visits her gynecologist
for a routine checkup and is found to have
white spots on her genitalia
HPI She complains of slight outer
vaginal itching but denies any
postmenopausal bleeding, vaginal
discharge, or drug intake
PE Hypochromic macules on labia
majora extending to perineum and
inner thighs in patchy distribution
with scale formation; skin is
thickened
Pruritus vulva
Causes:
General
Local
Psychosomatic
Idiopathic
General Examination
Local examination:
Smears
Culture and sensitivity
BIOPSY: KEYEs Dermatological knife
BENIGN LESIONS OF THE Vagina
CYSTIC SWELLINGS
SOLID TUMORS
ATROPHIC VAGINITIS
VAGINAL ADENOSIS
Cystic swellings
Gartners Cyst
Dilatation of the Gartners (Wollfian) duct
Anterior and lateral vaginal walls
Epithelial inclusion cysts

Endometrioma
Uretheral diverticulum
Solid Tumors
Fibromyoma
Condyloma accuminata
Bilharzial polyps
Atrophic vaginitis
Thinning and atrophy of vaginal
epithelium
Most common in postmenopausal

women with low estrogen levels
Dyspareunia and vaginal spotting

(differential includes uterine cancer)
Vaginal Adenosis
Persistent Mullerian columnar
epithelium in the anterior wall
and upper 1/3 of vagina
Manifestation of maternal DES

exposure
Red, granular patches
Precursor of clear cell

adenocarcinoma
Vaginal Adenosis
Note the red granular patches on the vaginal mucosa on

the left. The slide on the right shows glandular
development.
Most patients are 7-35 years of age
BENIGN LESIONS OF THE cervix
CERVICITIS
EROSION
POLYPS
Inflammatory Lesions of the Cervix
Cervicitis (acute)
Symptoms: backache, bearing-down feeling in the
pelvis, dull pain in the lower part of the
abdomen, urinary tract symptoms

Erosion of the Cervix
Characterized by columnar epithelium replacing squamous
epithelium, grossly resulting in an erythematous area
Causes:
Physiological:
Cervicitis: Acute or Chronic
Hormonal therapy
Erosion of the cervix following delivery. A normal cervix

is on the left
SMEAR
If infection---- Treat cause
IF CIN ------ Manage according to stage

Chronic Cervicitis
Chronic inflammation, sometimes ulceration with repair,
atypia or dysplasia, nabothian cysts from endocervical
glands
Backache is a common symptom

Chronic Cervicitis
Nabothian Cysts
Endocervical glands blocked by inflammation or

scarring.
Chronic Cervicitis
Chronic inflammation underlies an area of cervical

dysplasia
Endocervical Polyps
Postcoital bleeding and
irregular vaginal spotting
Inflammatory
proliferations of cervical
mucosa; not true
neoplasms
Soft; may protrude
through the cervical os

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Benign diseases of the

vulva, vagina and cervix

According to the International Society for the Study of

Benign tumors, hamartomas and cysts

1. Lichen sclerosus 12.Psoriasis

1. Familial benign chronic

1. Bartholin cysts 8. Hidradenoma

2. Epidermal inclusion cyst (Dermoid cyst) 9. Lipoma

3. Endometriosis 10. Chronic Inflammatory swellings

4. Hydrocele of the canal of Nuck 11. Hemangioma

5. Skene duct cyst 12. Lymphangioma

6. Seborrheic keratosis 13. Angiokeratoma

7. Acrochordon (fibroepithelial polyp) 14. Pyogenic granuloma

8. Fibroma, fibromyoma, and dermatofibroma 15. Sebaceous gland hyperplasia

ATROPHIC LICHEN (LICHEN SCLEROSUS ET ATROPHICUS)

LICHEN SIMPLEX CHRONICUS

Medial to labia minor

Blockage of duct following infection

A fungus, usually of the class Ascomycetes,

Any of various skin diseases characterized by

Most patients are post-menopausal women

Stenosis of the introitus develops

Note the white, parchment-like or plaque-like lesion

During early stages the patient may not have symptoms.

Some patients develop intractable pruritus

Burning and pain are less likely manifestations.

Figure-of-8 or keyhole configuration.

In late stages normal architecture may be lost

Squamous cell carcinoma develops in 3-6% cases

Thinning of the surface epithelium with some

Testosterone propionate is ineffective and has

Close follow-up -----epithelial cancer.

influences or exposure to exogenous irritants

Precursor of squamous cell CA if cells are

This lesion produces hyperplastic thickening of the

Note the keratin horn cysts and the infiltrate of

ITCHING is a common symptom.

If hyperkeratosis is not prominent, lesions may appear

The clitoris, labia minora, and inner aspects of the labia

Extensive lesions may result in stenosis of the vaginal

Repetitive scratching or rubbing from irritants

Treatment is aimed at halting the

Hyperkeratotic, usually ill-defined,

Usually located over the labia

Itching is always present and may

Lichen simplex chronicus may be associated with

Malignancy is possible in long-standing and ulcerative

Itching is rare, but pain, burning,

Epithelial inclusion cysts

Most common in postmenopausal

Dyspareunia and vaginal spotting

Manifestation of maternal DES

Red, granular patches

Precursor of clear cell

Note the red granular patches on the vaginal mucosa on

Symptoms: backache, bearing-down feeling in the

pelvis, dull pain in the lower part of the

abdomen, urinary tract symptoms